An article by Lorcán Mac Mathúna on medicine and ethics based on a discusion with Dr Christopher Cowley, Lecturer in Philosophy, UCD

Autonomy

Although the autonomy of the individual is generally valued as a principle in western liberal democrocies there are two justifications for intervention in personal liberty. The first justification is the harm principle. If what I do is harmful to anyone else I should not be allowed do it. This is an uncontroversially accepted principle in western democracy.

The second more controversial principle is paternalism, where the state can intervene, possiblty against our wishes, when it comes to matters that would be in our interest. There are many occasions where our autonomy is restricted for the good of others and for our own good; the question is whether End of Life Decisions is one of these contexts.

CP_E_MedicalConsequences - Doctor consoling patient

Normally paternalistic clinical decisions are made on the basis that the patient will be grateful later on when their condition improves. In end of life decisions we are talking about possibly irreversible decisions so how can we say whether the person will be grateful later on.

You could say that euthanasia is a red herring: that the real question is how we treat the elderly. The more important question, especially with an ageing demographic, is what are we going to do about older people. And the question is not ‘how do we manage the elderly as a class;’ but why is the attitude towards the elderly so lacking in empathy and respect. Why are resources for the elderly; homes, palliative care, etc., of such inadequate standard? When we look at the matter from this angle euthanasia becomes an artificial question deflecting from the more urgent issue that the alternatives to dieing are so bleak in so many cases. So rather than talking about euthanasia as a quick fix and dressing it up in the language of autonomy, we should be looking at why resources for the elderly and palliative care resources are below par. Surely we should be able to look forward to a comfortable twighlight period.

 

Dependencies

Autonomy is one of the primary concepts on which euthanasia is discussed but autonomy is perhaps the wrong term to focus on because it makes it sound like the ideal we should all aspire to is personal independence. That we as healthy young and middle aged, financially independent people, have reached this apotheosis where we are in control of our own lives and of society, without accepting that all of us are dependent throughout our lives, its just a matter of degree. Perhaps opur focus should be a more rounded discussion on autonomy; that it might not be such a guiding concept as the western tradition has it. Maybe we should be talking about different degrees of dependence and different kinds of dependence as we move into old age.

Imagine a different scenario,which would require we adjust our concept of values. In a society where venerability and wisdom are valued old people have a very valid and necessary societal function, and young people are dependent on them. In truth every society benefits from this wisdom of experience; and we all need to recognise our interdependence.

 

Advanced directives and dementia

There is a philosophical argument that asserts that if you can’t remember being a person in the past, then you are no longer that person. That we are who we remember being and that it is not just a matter of bodily continuity. In the same way people of good conscience would feel uneasy about punishing old war criminals who genuinely can’t remember that atrocities they are accused of committing,(We can’t punish them in the full sense of punishment: we can lock them up but it is not reformative and the prisoner doesn’t see that justice is being done. S/he is just bewildered and doesn’t see his/her condition as a consequence of actions) it is tempting to say that the advanced directive of a person who is now in a state of dementia is no longer a valid reflection of the will of the person who now exists in a different reality.

This subjective philosophy has its counter that there are residues of the past in that person’s life such as children, personal items, etc. It highlights the danger, or rather the deficiencies of advanced directives, which never take every conceivable sequence of developments into account and in most cases end up being inapplicable to the developing clinical condition of the incompetent patient. The ideal advanced directive would speak of the life values accumulated in the arc of a persons life and would not be simply a statement of the persons opinion of preference during a moment of their life.

 

The Ethics of Acts and Ommissions

Is it ok to let somebody die when you could do something to prevent it? Take the example of a child drowning in a shallow pond. In terms of legal and moral responsibilities, if the proximity is close and the action required is low cost; and you are competent to take that action; then you have a moral obligation to act. The moral obligation does come with the question of what is close proximity, what is a great cost or risk, etc., all of which make it difficult to define the concept. Like many ethical issues it starts with an intuition and the ethics are built to solidify this. This difficulty to tangibly define this obligation is manifest through absence in common law where there is no legal obligation to act - In English as in Irish law there is no Good Samaritan clause. In contrast, in French law; there is an explicit duty of care in these circumstances.

There is a utilitarian frame of thinking that there is no difference between acts and omissions. That if the result is the same that the cause is morally equivalent. This is one of the arguments for liberalising euthanasia: that people’s death is hastened when they receive some forms of treatment for pain; that there would have been no difference in the length of their lives if they were just euthanized; therefore morally there is no diference between the two actions. The question it poses is whether there is a difference between acts and omissions. The following example of the nephew in the bath, in one form or other, is often cited.

A child is in the bath and he drowns whilst his uncle is in the room watching. Nobody else knows what happened in the room but it is clear that the uncle either held the boy beneath the water or that the boy was unconscious and that the uncle let him drown. Knowing that either one of these circumstances must have been true is the uncle a murdered regardless of what he did? The utilitarian argument says yes and morally the callousness of the second scenario is damning, but is it murder?

The counter intuition is that the act is different to the omission especially if it involves bodily contact. Holding the boy underneath the water seems a lot more serious from the point of view of personal responsibility; than doing nothing. Bringing this rational into the clinical context; is there a difference between withholding antibiotics or not rescusitating as might be called for in an advanced directive, and administering a poison? Whereas the answer may clearly seem to be yes that surely there has to be; it leaves the conclusion open to the paradoxical interpretation employed in the Anthony Bland and Terry Schiavo cases. Here we have the willing of a person’s death by doing nothing, by letting them starve or die by dehydration. But perhaps this again is a case of framing the issue in the wrong argument. Maybe what we have here is a distinction between medical care and basic care –where basic care is not only food and water but also hygiene- which brings us back to the concept discussed earlier of what actions are morally obligatory based on assements of proximity, cost, and competence.

Although it provides material for thought, the heading ‘acts and omissions’ does not give satisfactory answers. But perhaps that’s because it is not the right concept with which to address the question. The Bland case would seem to point to anomalies which lead to a cruel and undignified termination of a person’s life. In some cases omissions leave the patient’s life to faith, for example: will the patient die from this untreated bout of pneumonia; and in other cases it can be a calculated campaign to kill the patient, for example: to starve the patient to death. Maybe the real context for analysis is the goal of care, where care of the patient’s present comfort and psychosocial needs is paramount.